Combined Epicardial and Endocardial Ablation for Atrial Fibrillation: An Updated Best Practices Guide to Hybrid Convergent Procedures

Non-paroxysmal atrial fibrillation (NPAF) accounts for approximately 40-50% of identified AF and is often accompanied by structural and functional atrial remodeling. Advanced disease can result in increased morbidity, mortality, and healthcare costs. Anti-arrhythmic drugs or endocardial pulmonary vein isolation are less successful in NPAF. Hybrid epicardial-endocardial (convergent) ablation is a treatment for advanced AF supported by a randomized clinical trial for which best practices were published in 2020. With gained clinical experience and evidence, herein is an update to hybrid convergent best practices, with a focus on recommendations where possible. This includes the establishment of a multidisciplinary hybrid AF team, patient selection criteria, procedural logistics and protocols, intraoperative considerations, postoperative management, left atrial appendage closure, patient/provider education, adverse event mitigation, and follow-up patient outcomes. Future directions are explored, including the use of alternative ablation energy sources and robotic-assisted techniques.